Though it’s not gotten much attention, an immense refugee emergency continues to unfold in South Sudan. In the young country’s Unity and Upper Nile states, roughly 170,000 Sudanese refugees are living in camps that were, for much of the summer, sprawling, muddy tracts of hardship and sickness. The refugees had escaped state-sponsored aerial bombardments in their homelands, but MSF’s epidemiological teams documented mortality rates in some of the camps well above, and in some cases double, the World Health Organization’s emergency threshold for refugee situations.

MSF, which had been working among the refugees in Yida, in Unity state, and in Upper Nile state’s Maban County, rapidly scaled up its response, adding scores of international and national staff , taking on tasks—drilling boreholes for water, for instance—normally outside its purview, and working around huge logistical challenges posed by both South Sudan’s war-torn history and the onset of the rainy season.

Below, along with images captured by award-winning photographer John Stanmeyer, is the story of MSF’s work in Yida as told by three people who saw a trickle of refugees become a flood—John Johnson, a nurse from Virginia; Matthew Horning, a doctor originally from Minnesota; and Andre Heller, a former member of the MSF-USA Board of Directors who hails from Colorado and is currently serving as MSF head of mission in South Sudan.

EARLY ON

Around 10,000 refugees arrived in Yida in late-2011, and the numbers stayed constant in the following months. That was about to change when Johnson and Horning arrived in early summer.

JOHN JOHNSON: Yida was described to me as a pretty small refugee camp. It just seemed like it would be a quiet, stable hospital project.

MATTHEW HORNING: When I arrived in Yida [in May], it was me and one other doctor… most of the people that seemed to be coming to the camp seemed to be in relatively good health, and we weren’t seeing high rates of malnutrition…. Over the eight weeks that I was there, fairly abruptly, we started noticing an increase in the acuity of patients. People were coming much sicker, and we noticed a spike in malnutrition as well.

JOHNSON: In the time it took me to go from Paris to Juba to Yida in June, the population increased by several thousand, so the figures I was given in Paris were already outdated by the time I arrived. About 1,000 refugees were arriving every day. By the time I got there, the population of the camp was about 45,000…. It just sort of exploded.

AN INFLUX OF NEW REFUGEES

Over the summer, the number of refugees in Yida reached around 60,000, stretching the capacity of the camps and of MSF to respond to their needs.

JOHNSON: Fast-forward about one month, and our hospital had grown from 16 [admitted] patients to nearly 40, and we were working as fast as we could to hire people, train them, work all of the shifts and take care of the patients, and build onto the hospital to expand our physical space. I was working as a nurse and hiring and training nursing staff. During that time we had more patients than we were really capable of taking care of, and we couldn’t admit all of the patients to the hospital that we wanted to.

ANDRE HELLER: We don’t have precise figures for Yida’s population, but it’s estimated at between 50,000 and 65,000 people.

HORNING: The camp got big enough where the limited water, sanitation, those sort of facilities, were completely maxed out to the point where people were just in this bad cycle of reinfection and illness, and for the children, that was a very bad combination.

JOHNSON: We had limited space, and we were forced to triage and admit the most critically ill. During the first and second weeks of July, our mortality rate went very high. About one-fourth of the children that we admitted died, most of them within the first 24 hours of getting to the hospital.

HORNING: We had only the most basic medications, equipment and laboratory tests. We did tests for malaria and we could do a basic urine test, and we could do hemoglobin and blood sugar, and that was it….We were treating respiratory illness and diarrhea; in the US, you would say it was [caused by] this bacteria and this pathogen, and this is what it looked like on an x-ray. And we had none of that, so we were using our clinical skills and our clinical judgment.

THE RAINY SEASON

A complicating factor was the onset of the rainy season, which washed out roads and left planes as the only option for resupplying programs that were now contending with new dynamics.

JOHNSON: The rains really picked up in mid-June, and we saw a drop in the refugee influx to the camp because they just couldn’t get there anymore. The roads from the Nuba Mountains where many of the refugees had come from—were washed out.

HORNING: From a health standpoint you kind of expect that you’ll see malaria cases rise as the rainy season starts…. You have rains that are six or seven inches coming three or four times a week, and you see all that standing water, and you can imagine [that] infectious disease is being sort of encouraged to spread.

JOHNSON: We also saw a spike in malnutrition and respiratory tract infections at the beginning of the rainy season, and in the last two weeks I was there, we saw a tripling of malaria cases in our outpatient department. And the next week they tripled again. You have to plan ahead for malaria, because once the mosquitoes start to breed, it begins to spread through the camp. We distributed mosquito nets and made sure we had a good outpatient department because malaria can be treated on an outpatient basis—it’s not that lethal if you catch it early. You also have to have a supply of blood available, in case people become acutely ill and require blood transfusions.

MSF SCALES UP

JOHNSON: The first month we were pretty much working from the time we got up to the time we fell asleep. We’d always have a quick morning meeting to discuss the major plans for the day, and then have a medical meeting to discuss any changes we needed to focus on. I’d check in with my national staff to make plans for the day. I did well over 100 interviews in the time I was there and hired about 50 people in two-and-a-half months, just to staff the hospital.

“The last two weeks I was there, we saw a tripling in malaria cases in our outpatient department. And the next week they tripled again.”

HORNING: There were other organizations in the camp that were also trying to help address a number of these issues, in particular water and sanitation and nutrition. And MSF, I think, worked as well as we could to coordinate with them and to try to address this, and ultimately [said], “This isn’t being addressed adequately. We are going to do it.” And by the time I left, [MSF had] water and sanitation specialists there, and we were in the process of opening our own inpatient nutrition program and an outpatient nutrition program.

HELLER: The MSF team has scaled up the capacity for pumping and storing borehole water so that we’re now [as of mid-September] able to provide 80,000 liters of clean and chlorinated water [Editor’s note: the standard in an emergency situation is 20 liters per person, per day]. We also distribute jerry cans, as we saw that the refugees’ jerrycans were dirty and contaminated, potentially transmitting infections. And we build public latrines. There were nowhere near enough and the camp’s population keeps expanding.

JOHNSON: We had two very, very challenging weeks during which we brought in a lot of team resources, hired a lot of people, and made a lot of changes in the hospital. We also opened some preventative projects—an outpatient therapeutic feeding program to help prevent malnutrition; a community health program to reach out and teach about hygiene and how best to use the limited amount of soap that people had, how to find clean water and wash utensils, jerrycans, and hands.

HELLER: MSF has increased the means deployed, mainly by increasing the number of hospital beds from 40 to 100 and expanding staff numbers. We’ve quadrupled our expatriate team: doctors, nurses, and water and sanitation experts too, because we’re intervening in hygiene and sanitation structures in the camp.

JOHNSON: There were always emergencies. Any time I was near the hospital I’d usually get pulled into the emergency room or into one of the wards to work on resuscitation or to discuss a patient. And then I did a lot of following up with the nurses and nurse assistants about their work, to make sure that the quality of care was good and improving. I also made sure the hospital was well-stocked with supplies and that we were keeping track of what we were using, because everything had to be fl own in by airplane, and we had to plan really far ahead to ensure we didn’t run out of anything.

SEEING RESULTS AND LOOKING FORWARD

HELLER: Between mid-June and mid-July, the mortality rates were twice the emergency threshold levels. One month later, the mortality rate in the hospital was down from 25 percent to 2 percent. But most deaths are still among children under five. They’re the most vulnerable ones.

“It was the most challenging ten weeks of my life. It’s a tragedy, and it was devastating to be there. We saw such high mortality, so many people dying. But also, being there and seeing MSF’s ability to respond quickly and make changes—to really bring about an improvement in the health and lives of the people in Yida—was really incredible.”

JOHNSON: It was the most challenging ten weeks of my life. It’s a tragedy, and it was devastating to be there. We saw such high mortality, so many people dying. But also, being there and seeing MSF’s ability to respond quickly and make changes—to really bring about an improvement in the health and lives of the people in Yida—was really incredible. It was an honor to be there.

HELLER: We’re seeing some 3,000 patients per week, who are hospitalized or treated as outpatients. We’ve multiplied our consultation sites so the children come earlier, before they fall seriously ill. And we give the malnourished ones adapted therapeutic foods…. We’ll need to monitor the refugees’ health and continue efforts to improve their living conditions. We’ve achieved a first step: the mortality rate has been reduced. Now we have to maintain the momentum over the next few months because the refugees’ situation in Yida is still precarious.